Low-risk prostate cancer (PCa) has historically been overtreated, exposing men to unnecessary morbidity. Emerging evidence supports conservative management of low-risk PCa without immediate radical intervention. Contemporary data show a marked decline in surgical overtreatment, with the proportion of radical prostatectomies yielding only Grade Group 1 cancers falling from 32.4% in 2010 to 7.8% in 2020 in the US SEER registry. Long-term studies confirm that deferring treatment is safe for low-risk disease, with PCa-specific survival exceeding 95% at 15–25 years for cohorts managed with surveillance. Major guidelines now endorse active surveillance (AS) as the preferred management for low-risk PCa. An alternative risk stratification system that expands the low-risk category was shown to reclassify 45–83% more men as low risk without increasing 15-year PCa mortality. Focal therapy has emerged as a potential middle-ground strategy, though evidence is still limited. The paradigm for managing low-risk PCa has shifted toward conservatism, with AS firmly established as the standard of care. Continued efforts to refine risk stratification and evaluate focal therapy are needed to further optimize individualized care, minimize harm, and maintain excellent cancer-specific outcomes for low-risk PCa. This comprehensive review aims to create a practical, risk-adapted framework for managing patients on AS. We will: (i) summarize inclusion criteria and outcomes, (i) compare AS follow-up schedules across major institutions and guidelines, (iii) provide evidence-based criteria to de-intensify surveillance in men with sustained stability and (iv) clarify the role of focal therapy as an intermediate treatment option within the AS continuum.

BACKGROUND:Work-related musculoskeletal disorders are a growing concern in surgical practice, particularly in the context of robot-assisted surgery. Physical strain can significantly impact the well-being and performance of surgeons and surgical staff. This study aimed to evaluate the prevalence and severity of surgical strain among urologists using different available surgical platforms. METHODS:An anonymized, web-based survey was conducted between March and October 2024 using the REDCap platform. Distributed via professional networks and social media, the survey collected data on demographics, surgical experience, platform usage, and self-reported physical discomfort. Statistical analysis included Mann-Whitney U and Chi-squared tests, with P<0.05 considered significant. RESULTS:A total of 427 urologists participated. Most console surgeons (up to 83% for one robotic system variant) reported some level of physical discomfort. Discomfort was also reported by 83% of open surgeons and 80% of bedside assistants, the latter of whom had the highest incidence of injury (53%) from robotic arms. A noteworthy subset of survey respondents required physiotherapy (13-15%), medical (6-11%), or surgical (2-3.8%) interventions due to physical strain. No significant differences were observed by age or sex among console users. CONCLUSIONS:Ergonomic strain is prevalent among urologic surgeons, regardless of surgical platform, with bedside assistants particularly vulnerable. These findings underscore the need for ergonomic training, physical conditioning, and design improvements in surgical systems to safeguard surgeon health and maintain procedural efficacy.

BACKGROUND:Minimally invasive surgical techniques (MISTs) are becoming an increasingly popular outpatient treatment option for lower urinary tract symptoms. Although generally well-tolerated, MISTs may cause periprocedural discomfort. Virtual reality devices (VRDs) have been shown to reduce patient-reported pain during several procedures. This study aims to evaluate whether the use of VRD during MISTs could improve perioperative endovenous sedation needs of a VRD during MISTs in a case-control design. METHODS:We retrospectively analyzed patient data from MISTs performed between January 2024 and July 2025 at a single referral center (ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy). Procedures were conducted with or without a VRD (HypnoVR®, Strasbourg, France), based on patient preference and device availability. Patients were grouped into MISTs without VRD (group 1) and MISTs with VRD (group 2). Periprocedural data, endovenous sedation needs, Visual Analogue Scale (VAS) score for pain, use of additional painkiller drugs after the procedure, and complication rate have been addressed. RESULTS:Twenty-one procedures with VRD and 66 control procedures were analyzed. Groups were comparable in age, prostate volume, PSA, indwelling catheter presence, and type of MIST. Median (IQR) prostate volume was 41 (30-56) mL in group 1 and 36 (30-45) mL in group 2. MIST distribution was similar, though iTIND procedures were more frequent with VRD. Endovenous sedation rate was higher in group 1 (86.4 vs. 38.1%, p < 0.001). Median (IQR) VAS scores were 2 (1-2) in group 1 and 1.5 (1-2.75) in group 2. No VRD-related side effects or procedure interruptions occurred. CONCLUSION:This is the first study demonstrating the safety, feasibility, and tolerability of VRD use during MISTs. Although VRD did not significantly reduce pain scores, it markedly decreased endovenous sedation use, potentially facilitating faster recovery and discharge. VRD may be considered for patients undergoing MISTs where available.

OBJECTIVES:To develop an international consensus on technical principles, training requirements, patient selection, and procedural best practices for retroperitoneal single-port (SP) robotic urological surgery through a structured Delphi methodology. METHODS:A five-step modified Delphi process was conducted in accordance with ACcurate COnsensus Reporting Document (ACCORD) guidelines. A total of 32 statements were formulated by a steering committee of expert robotic surgeons and distributed to an international panel of 16 urologists from five countries. Consensus was defined as ≥70% agreement with <15% disagreement using a 9-point Likert scale. Statements without consensus after the first round were discussed, revised, and re-voted during an in-person meeting (Naples, Italy, July 2025). Internal reliability was evaluated with Cronbach's α, and inter-rater concordance with Kendall's W. RESULTS:A total of 14 experts participated in Round I and 12 in Round II. Consensus was achieved for 22 of 32 statements (69%), primarily addressing general principles, surgeon training, patient selection, access techniques, and perioperative management. Agreement was highest for the need for structured and proctored training (92.9%), suitability of low-complexity renal tumours as index cases (78.6%), and feasibility of the lower anterior access to enhance recovery (84%). No consensus was reached on absolute contraindications, specimen extraction protocols, or standardised criteria for platform selection in obese patients. Reliability of expert ratings was excellent across rounds (Cronbach's α = 0.98 and 0.92). CONCLUSIONS:This Delphi study provides the first international consensus defining principles and technical considerations for retroperitoneal SP robotic surgery. These consensus recommendations represent a key step toward standardisation and safer clinical adoption of SP retroperitoneal surgery, while highlighting areas needing further evidence.

Abstract Objective The aim of this paper is to evaluate fellowship outcomes 10 years after implementation of the European Association of Urology Robotic Section (ERUS) structured curriculum for robot‐assisted radical prostatectomy (RARP), with a focus on completion rates and reasons for non‐completion. Subjects and methods Data were obtained from institutional records and a trainee survey. The primary outcome was fellowship completion (i.e., Certificate of Excellence achievement). Secondary outcomes included reasons for non‐completion and satisfaction. Completion rates were analysed annually, with trends assessed using the Cochran–Armitage test and log‐linear regression for the Estimated Annual Percentage Change (EAPC). Comparisons before and after introduction of a procedural diary (2023) and between pandemic and non‐pandemic years used Fisher's Exact Test. Results Among 126 fellows, a total of 42 (33%) completed the fellowship by achieving the Certificate of Excellence. The trainee survey achieved a response rate of 77%, supporting the representativeness of the collected data. The main barriers to fellowship completion included limited console access (49%), insufficient programme duration (20%), logistical difficulties (20%) and COVID‐19‐related disruptions (11%). Despite these limitations, overall satisfaction with the fellowship was high (83%), with particularly strong approval of the ORSI hands‐on training week (100%). Completion rates demonstrated a progressive increase over time, rising from 20% in 2018 to 52% in 2023. The Cochran–Armitage test confirmed a statistically significant upward trend in completion rates over the study period ( p < 0.001), while log‐linear regression analysis showed a numerical but non‐significant EAPC of 13% (95% CI –0.6 to 28.6). Although 2023 represented the highest observed completion rate, this peak was not significantly different from previous years (OR 2.63, 95% CI 0.91–7.63). Conclusions The RARP ERUS Fellowship remains a benchmark in robotic training, but unsatisfactory completion rates highlight the need for improvement. Recent reforms, including the procedural diary, show promise and warrant expansion.

BACKGROUND AND OBJECTIVE:Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is increasingly used for prostate cancer staging. However, the diagnostic role of molecular imaging for patients with rising prostate-specific antigen (PSA) levels following radical prostatectomy and postoperative radiation therapy remains unknown. We performed a systematic review and meta-analysis to assess the diagnostic performance and recurrence patterns detected by PSMA PET in this specific setting. METHODS:PubMed/MEDLINE, Cochrane library's Central, EMBASE, and Scopus were searched from database inception to September 1, 2025. Studies reporting PSMA PET findings in men with rising PSA levels after radical prostatectomy and postoperative radiotherapy were included. Pooled detection rates were calculated using random-effects meta-analysis. Site-specific recurrence patterns and PSA-dependent positivity were analyzed. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2, and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. KEY FINDINGS AND LIMITATIONS:A total of eight studies including 940 patients were analyzed. The pooled PSMA PET positivity rate was 83% (95% confidence interval [CI]: 0.75-0.89), with significant heterogeneity. When stratified by site, positivity rates were 7% for local recurrence, 42% for nodal disease, and 31% for distant metastases. PSMA PET positivity increased with PSA level, from approximately 72% at a PSA level of 0.2 ng/ml to >90% at a PSA level of ≥2.0 ng/ml. Interpretation is limited due to heterogeneity, observational designs, and incomplete reporting of key clinical variables. CONCLUSIONS AND CLINICAL IMPLICATIONS:The use of PSMA PET demonstrates high detection rates in men with rising PSA following radical prostatectomy and postoperative radiation therapy, even at low PSA levels. Recurrence is rarely located in the prostatic bed and more commonly involves nodal or distant sites. Despite limitations in evidence certainty, these findings support PSMA PET as a valuable restaging tool in this setting and underscore the need for further studies to optimize its timing and integration into salvage treatment strategies. PATIENT SUMMARY:In this study we explored how well the PSMA PET works as a diagnostic tool in the setting of a PSA increase after radical prostatectomy plus radiotherapy. We found that PSMA PET was informative about the location of recurrence at an early stage, even at low PSA levels. These results may help clinicians in the early diagnosis of recurrent prostate cancer and in potential salvage treatments.

BACKGROUND:Robot-assisted partial nephrectomy (RAPN) with the novel Da Vinci® Single Port can be performed either in a standard flank position (flank approach) or in an innovative supine decubitus (namely, Supine Anterior Retroperitoneal Access [SARA]). Based on low quality retrospective data, the latter is advocated to provide crucial advantages in the quality of care. OBJECTIVE:To demonstrate that the SARA approach compared to the lateral approach portends lower intra-operative adverse events (anesthesiologic and surgical), faster postoperative patient recovery (lower pain, shorter time to first walk, feed and canalization) without jeopardizing oncological safety (positive surgical margins). DESIGN, SETTING, AND PARTICIPANTS:The K-3 study is a single-center, patient-blinded, randomized clinical trial aiming to recruit 124 patients candidate to RAPN for clinically T1 single renal masses. A 1:1 randomization will yield two equally sized arms of study (namely, lateral approach [n = 62] vs SARA approach [n = 62]). The trial has received ethical approval (CETL 3 n°5448) and is registered on ClinicalTrials.gov as NCT07234409. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:The primary end point of the trial is the rate of achievement of a trifecta composed by 1). Absence of intraoperative adverse events graded according to Intraoperative Adverse Incident Classification (EAUiaiC) proposed by the European Association of Urology; 2). Negative surgical margins; 3). Hospital discharge within 24 h from surgery. CONCLUSIONS:K-3 trial will provide the first, most unbiased, highest-quality, real-World data concerning a topic of paramount importance in both anesthesiologic and urological field, potentially able to change the how RAPN is conceived, planned and performed. PATIENT SUMMARY:Partial nephrectomy for localized renal masses, with the Da Vinci® Single Port system, in supine decubitus might enhance intraoperative anaesthesiologic assistance, minimize postoperative pain and reduce hospital stay without threatening oncological safety, compared to the standard flank position.

INTRODUCTION:Bacillus Calmette-Guérin (BCG) immunotherapy remains the standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC). While the European Association of Urology (EAU) guidelines recommend initiating BCG treatment no later than 4-6 weeks following transurethral resection of bladder tumors (TURBT), delays in BCG administration are not uncommon due to factors such as pathological assessment timelines, patient-related issues, healthcare system limitations, and drug shortages. This systematic review aims to evaluate the impact of delayed BCG therapy or unconventional schedules on oncological outcomes, trying to establish the best treatment option for these patients. EVIDENCE ACQUISITION:A comprehensive literature search was conducted across multiple databases (PubMed, Scopus, Web of Science) for studies published from January 2010 to the present. After screening 262 publications, relevant prospective and retrospective studies, systematic reviews, and meta-analyses were included. EVIDENCE SYNTHESIS:We retrieved 14 manuscripts evaluating different BCG schedule or doses. Only two papers specifically referred to the delay in the treatment of high risk NMIBC. The findings highlight that the delays in initiating the BCG therapy beyond 6 weeks are associated with worse recurrence-free survival (RFS), progression-free survival (PFS), and cancer-specific survival (CSS) rates. However, evidence on the progression to MIBC or metastatic disease remains inconclusive, with only a few studies suggesting a potential impact. Despite these delays, even reduced dose or shortened BCG regimens appear to offer some level of protection against disease progression. CONCLUSIONS:This review emphasizes the importance of adhering to standard BCG treatment schedules to minimize the risk of recurrence and suggests that, in cases of unavoidable delay, strict endoscopic follow-up is crucial and an optimal treatment in case of cancer relapse must be offered. Further prospective studies are needed to conclusively determine the long-term effects of delayed therapy.